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Jump Start Toddler Program
Please fill out one from per child. For any questions or concerns, please contact Tiffany Demmon at museum.education@ttu.edu or call (806) 742-2432
Parent/ Guardian Name
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Address
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City
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Zip
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Phone Number
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E-mail
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Student's Name
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Student's Age
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Student's Gender
List any illnesses, allergies, medical conditions, and/or behavior issues of which Museum staff should be aware. (Confidentiality will be maintained)
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Consent to Media Coverage/Participation: I herby give permission for the name of the name of the minor listed below to be released to the media or for him/her to participate in any media coverage which might transpire during the course of the program. I authorize the use of the minor's name, biography, likeness, voice, and performance in the production of the program(s) and for the purpose of the publicizing and promoting the program(s) and/or future related programs. I represent that I am a parent (guardian) of the minor whose name is listed below and I hereby agree to have my child participate in media coverage. * *
Please check which class you would like to register your child.
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I certify that the above information is correct to the best of my knowledge. (Please print name below)
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